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International Surgery Journal

Kumar B et al. Int Surg J. 2016 Nov;3(4):2087-2091 pISSN 2349-3305 | eISSN 2349-2902

Original Research Article

Prospective study to correlate the level of glycosylated haemoglobin
with wound healing, vasculopathy and neuropathy
in diabetic foot patients
Brajkishor Kumar, Manish Kumar Mishra*, Ajit Sinha, Rajesh Kumar Soni,
Dharmendra Kumar Patel

Department of Surgery, VMMC and Safdarjung Hospital, New Delhi, India

Received: 11 July 2016
Accepted: 10 August 2016

Dr. Manish Kumar Mishra,

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.


Background: Diabetes mellitus is a prevalent global health problem and diabetic foot represents one of its dreadful
complications. Early aggressive approach and multidisciplinary intervention prevent limb loss and disease fatality.
Glycosylated haemoglobin (HbA1c) reflects long term glycaemic control and helps in prediction of complications as
well as response to treatment.
Methods: A total of 50 patients with diabetic foot ulcer (Wegner grade 1, 2) made nucleus of this study. Every
patient underwent proper clinical, hematological and sonological assessment. Optimum treatment was provided and
the effect of improvement in HbA1c value was correlated with duration of wound healing, vasculopathy and
neuropathy over a 12 week follow uu.
Results: Mean age of presentation was 53.4 years and patients developed diabetic ulcers (Wegner grade 1, 2) at a
mean HbA1c value of 6.6. Foot trauma was inciting event in 70% cases. 70% patients had neuropathy and 30% had
vasculopathy at presentation. Mean duration of healing was 42.6 days. Healing was faster in the group with lower
HbA1c; however there was no improvement in neuropathy or, vasculopathy in 12 weeks duration.
Conclusions: Based on the observations of present study it may be submitted that lower HbA1c value contributes to
faster wound healing, however it doesn‟t improve neuropathy and/or vasculopathy over duration of 12 weeks.

Keywords: Diabetic foot, Foot ulcers, Glycosylated haemoglobin, Neuropathy, Vasculopathy, Wound healing,
Wegner grade

INTRODUCTION diabetes, have been implicated as the primary underlying
risk-factors in the development of foot-ulcers while
Diabetes mellitus is one of the commonest global non- hyperglycemia contributes to delayed and impaired
communicable health-care problem, carrying a predicted wound healing.4
pandemic score of 366 million population by 2030.1
According to the ICMR-INDIAB study, there are 62.4 Treatment of diabetic foot syndrome involves
million people living with diabetes in India alone, making multidisciplinary approach in achieving euglycemia and
it “diabetic capital” of the world.2 About 15% of all such needs serial debridement/ disarticulation/ amputation as
patients develop a foot ulcer in their lifetime.3 per the grade of ulcer/ foot gangrene, else it could be life-
Neuropathy and ischemia, two common complications of threatening to the patient.

International Surgery Journal | October-December 2016 | Vol 3 | Issue 4 Page 2087

vibration wound healing. in collaboration with the arterial sonography of both lower limbs.standard  Patients with S. 4 and 5 (Wagner comparison between qualitative data was determined by classification). decreased sweating. clinical re-assessed at 12 weeks. history of numbness. METHODS Radiological investigations The proposed study was conducted in the department of Vasculopathy assessment by ankle brachial pressure surgery. 4 patients lost to follow-up. version  Pregnant ladies 16. Proper treatment was provided and they were history (for improvement in symptoms). department of biochemistry. The mean age following treatment) of presentation was 53. Statistical analysis Exclusion criteria Data was fed into Microsoft excel format in computer and was analyzed using SPSS statistical software. At physical examination.5. examination (for ulcer healing. median (min-max) as appropriate. The  Diabetic foot ulcers grade 3. Int Surg J. culture-sensitivity report. Categorical variables were presented as numbers and  Age >80 years continuous data was presented as Mean (+/. P-value less than 0. and moist dressings applied. due to hemoglobin‟s exposure to plasma glucose. 60% had short history of diabetes (less History than 5 years) and there was preceding history of foot International Surgery Journal | October-December 2016 | Vol 3 | Issue 4 Page 2088 . Vardhman Mahavir medical college and index (ABPI) using hand held Doppler and duplex Safdarjung hospital. limb. corns/callosities and ulcer/abscess of lower limb. vasculopathy and neuropathy in diabetic foot patients. New Delhi.6 Although it is clear from pulses.3(4):2087-2091 Glycosylated haemoglobin (HbA1c) is a measure of Duration and family history of diabetes. touch sensation by Semmes Weinstein filament. applying chi-square or Fischer exact test. foot patients is less well defined.4 years with a male (70%) preponderance.  Diabetic foot ulcers grade 1 & 2 (Wagner Classification). ulcer evaluation literature review that strict glycaemic control prevents and neurological examination using pinprick sensation. surgical at regular intervals and ulcers were debrided surgically. All had unilateral limb involvement. 2016 Nov. outpatient department and diabetic foot clinic with lower Appropriate antibiotic(s) was advised as per the tissue limb ulcers were selected on the basis of clinical history. were examination of patient. They were assessed at the time of first Patient work-up (At presentation and at 12 weeks presentation and at 12th week of treatment. thorough Total 54 patients. compliance to „beta-N-1-deoxy fructosyl component‟ of haemoglobin. treatment. HbA1c enrolled in the study and received optimal treatment from assessment as well as duplex arterial sonography of lower department of surgery at Safdarjung hospital. peripheral pulsations. Inclusion criterion biochemically (HbA1c value) and sonologically (ABPI as well as Duplex arterial flow pattern).5 American Diabetic Association has included HbA1c in the diagnosis of diabetes mellitus. palpation of all peripheral with a cut-off value of 6. limb and ulcer. fasting and post-prandial blood sugar level. complications. Haematological investigations The objective of this study was to co-relate the influence of level of glycosylated haemoglobin on wound healing. the relationship amongst HbA1c value. department of radio diagnosis and department of microbiology over a period Treatment approach of 18 months. New Delhi.05 were committee. Haemogram. vasculopathy and neuropathy in diabetic sensation by 128 Hz tuning fork and ankle reflex. renal function test and HbA1c assessment. RESULTS Data was collected at presentation and at 12 weeks of holistic treatment using proper history. signs of chronic limb ischemia. patients were followed up Patients presenting to surgical emergency. depicting the average blood glucose level over previous Clinical examination 2-3 months span. intervention and written informed consent taken. blood investigation and duplex 12th week of treatment. which is formed by non-enzymatic glycation pathway. India. Clinical nutritional assessment. patients were re-assessed by ultrasound. creatinine > 2 mg/dl deviation) or. All patients were informed about the considered significant. features of limb ischemia and neurological deficits). Continuous data was compared by student T-test/ Man Whitney U-test Study protocol submitted for approval to local ethical wherever required. Under strict glycemic control. Kumar B et al. complying with inclusion criteria.

6±17 in patient group with HbA1c up to 6. Mean duration (days) of Mean duration (days) of wound healing in two groups ±std. Mean (Table 1). Mean duration of wound healing was 42. Mean Age patients and Mean glycosylated patients at patients at Total number dev.5 (mean 7.5 53. pre and post treatment HbA1c values.3(4):2087-2091 trauma in most (70%) cases. grade of foot ulcer. sex. grade of foot haemoglobin +/.5 patient group with HbA1c more than 6.5±20 P-value 0. International Surgery Journal | October-December 2016 | Vol 3 | Issue 4 Page 2089 .5 N = 50 N = 50 P-value = 0.9 to to years 6. objective change was noted in vasculopathy and neuropathy in follow-up (Table 2). Neuropathy glycemic status of population improved (mean HbA1c (predominantly sensory) was noted in 70% patients. wound healing +/.2±0.5 6. dev.1±0.5 (39 days versus 46.48 Table 2: Mean duration of wound healing and its correlation with HbA1c value. yet 25 patients retained their value higher than 6. Sensory 15 Neuropathy 23 Motor Neuropathy No Neuropathy 5 10 12 Post tibial art vasculopathy No vasculopathy Ant tibial art vasculopathy 35 Figure 1: Number of patients with neuropathy.5 6. Both these patients had pre-treatment Figure 2: Number of patients with vasculopathy.7 25 25 25 25 07.5 at 12 weeks of treatment.5 39±13. However no subjective or.1 46. dev. Number of Number of Number of Mean HbA1c(±std.5 days). Kumar B et al.6 days (Wagner grade 0). Int Surg J. with HbA1c with HbA1c more than 6. Table 1: Age.5 presentation value value Less Less than than Wegner More More Wegner At 0 At 12 or or At 0 At 12 Male Female Grade than than Grade 1 week week equal equal week weeks 2 6. presentation 12 weeks of patients group with value dev. ulcer at std.13 mean glycosylated haemoglobin value 8. Healing was earlier in patients whose HbA1c was less than or equal to 6. which remained 8.std. dev. 2016 Nov.5 while 30% had vasculopathy (Figure 1. though the diabetic ulcer and 16% had grade 2 ulcers.) of patient (years)±std.16 N = 50 N = 50 P-value = 0.5 07. Mean duration (days) of wound healing Mean duration (days) of wound healing in 42.6±0. 84% had Wagner‟s grade 1 Following 12 weeks of holistic treatment.23). glycosylated haemoglobin level of study population was 6.7 06. In two patients foot ulcer worsened to higher grade and needed amputation. 2).65.4±0.6 and 25 patients had value higher than 6.4±11. 6.4).5 35 15 42 08 06.

5 during treatment.358(24):2560-72.6 In ADVANCE trial. It is advisable to screen predicted to double between 2000 and 2030. Kumar B et al. Clinical different populations. N Eng J Med. Little R. With early foot syndrome is a complex and heterogeneous disorder detection and prompt intervention.8. Selvin E. 2007. 2012. as well as once in their lifetime with relevant consequences both on family members. Estimate of An analysis of glycated hemoglobins by diabetic peripheral neuropathy varies from 9. Kasru A.1 Diabetic the population for diabetes at an early age.356(3):213-5. despite shorter duration of this disease well as at Diabetes has become one of the largest global healthcare relatively lower HbA1c value. Obesity and with the demographic data obtained during a study diabetes in developing world . Shahi SK. and its role in management of diabetes is well established.8. Vileikyte L. Association of HbA1c. Parial R. Neal B.5(4):906-14. Christman et al in their study at The advance collaborative group. Suppl):11S-19. Hasan CMM. here the presenting population is younger. El Nahas M.14 classification of diabetes mellitus. 2016 Nov.366:1719-24. should be educated about importance of lower limb and general morbidity.12 9.5 years. American diabetic association.India more HbA1c have foot ulcers. Chalmers J. Margolis DJ. Peterson CM.5 HbA1c Funding: Funded by Hospital value was found to drastically reduce the macro and Conflict of interest: None declared microvascular complications. Singh SK. Ahmad MNU. even mild. 50% patients) isolated from tissue culture specimen. the average duration of diabetes mellitus was 4.11. Kumar S.9.7 Ethical approval: The study was approved by the institutional ethics committee Prevalence of diabetic foot complications increases with age and duration of disease. Lancet. Christman AL. the wound area healing rate per 2008. In this study. The global burden of diabetic foot their study over prevalence of diabetic foot ulcer and disease. Patients. For each 1. Intensive blood John Hopkins Wound Center.INDIAB) study: methodological at a mean value of 6. So. What is hemoglobin A1c? Neuropathy was noticed in 70% cases. In contrast to the West. Boulton AJ. foot infections etc. disastrous disease. a target 6.33(Suppl 1):S62-69. Int Surg J. was no improvement in vasculopathy or. Singh TB. Laing P. J Invest Dermatol. MacMohan S. diagnosis and been reported in other studies over diabetic foot ulcers.1%). Hemoglobin A1c is a predictor of as neuropathy is well established since long. 2011.0 with type 2 diabetes. shorter duration of problems of the century and the burden of disease is diabetes.3 Presently there is no strict glycemic control.13(10):2121-7. 1998. where glycosylated haemoglobin was up to 7. Goldstein D.8 Though association 8. neuropathy with 2011.5 years. we noticed that presentation of diabetic foot 10. Staphylococcus aureus was the commonest microbe (in 5. which is in accordance 1. 3. however a good glycemic control has been proven to retard the progression of complications ACKNOWLEDGEMENTS like neuropathy. found mean 4. improvement in HbA1c over 12 week span. Authors would like to thank Dr.6-78% in electrospray ionization mass spectrometry. 1998. The development and complications of duration of diabetes to develop foot ulcers 11. Patel A. angiopathy. Pradeepa R. Lazarus GS. foot care and early reporting of absolute way to prevent the development of this changes to health care professionals. sub-group. however they were present diabetes (ICMR . details.6 in our study. Similar prevalence of vasculopathy has 6. J Diabetes Sci Technol. Prevalence of diabetic foot ulcer and CONCLUSION associated risk factors in diabetic patients from North India. England J. which was of relatively shorter duration. limb loss and other which affects 1 out of 7 patients with diabetes at least morbidities could be minimized.176(2A 70% of our patients had preceding history of foot trauma. Bhawna for her HbA1c reflects glycemic control over past 2-3 months assistance in analyzing the statistics of this study. USA found similar inverse glucose control and vascular outcomes in patients association between it and rate of healing.028 cm2.a growing challenge. is harmful. unit increase in HbA1c. The Indian council of medical research . 2005.10 In present study.13 Our 30% patients had features of Chemistry. Gupta SK.4(3):83-91. Kumar A. Diabet Care. which mean age with foot ulcer was 55. day decreased by 0. between high HbA1c and peripheral vasculopathy as well Garza LA. associated risk factors in North India.3(4):2087-2091 DISCUSSION neuropathy. 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